Health Disparities, Systemic Racism, and Failures of Cultural Competence

Reducing Racial Inequalities in Prostate Cancer Treatment: Healthcare Access Barriers

Inequalities in healthcare for patients with prostate cancer can result in treatment and mortality disparities. Despite Black men with prostate cancer having higher incidence and mortality from prostate cancer, the study by Hammarlund and colleagues found that they are less likely to receive appropriate treatment compared with their White counterparts. Given that Black men with prostate cancer have similar or better survival when participating in clinical trials or receiving equal treatment from an equal access to healthcare system, identifying factors contributing to inequitable treatment is essential to improve the overall health and survival of Black men with prostate cancer. See related article by Hammarlund and colleagues, Cancer Epidemiol Biomarkers Prev 2024;33:435-41.

Health Disparities Curricula in General Surgery Residency Programs: A Critical Scoping Review

INTRODUCTION

In 2021, the structural determinants of health (SDOH) were added to the Accreditation Council of Graduate Medical Education common program requirements for all accredited residency programs, including general surgery. In this study, we sought to explore the current scope of, and concepts used in, health disparities curricula for general surgery residents, specifically investigating how general surgery residents learn about health disparities and the SDOH.

METHODS

We searched PubMed, EMBASE, Education Research Complete (EBSCOhost), and Web of Science Core Collection using keywords related to health disparities and the SDOH. Inclusion criteria consisted of all studies published after 2005 that discussed health disparities curricula for Accreditation Council of Graduate Medical Education-accredited general surgery residency programs. Five thousand three hundred seventeen articles were screened using a two-phase process. Data extraction and analysis was performed using critical review methods.

RESULTS

Seventeen articles were identified. Within these articles, seven unique health disparities curricula were found. All seven of the identified curricula employed cultural frameworks as methods to mitigate health disparities. Three curricula, all published after 2011, included education on the SDOH. A wide variety of educational methods were utilized; in-person didactics was the most common.

CONCLUSIONS

In the current literature, culture continues to play a large role in health disparities training for general surgery residents. Though further efforts are needed to understand the methods used in programs that have not published scholarly work, it is imperative to ensure that residents are provided with the sociopolitical perspective needed to understand the SDOH and serve all patients, including those affected by health disparities.

The patient perspective on diversity-sensitive care: a systematic review

BACKGROUND

The provision of diversity-sensitive care is a promising approach towards reducing health disparities. Recent criticism and a scientific gap demonstrate the need for the patient perspective on diversity-sensitive care. This systematic review aims to describe the patient perspective, including patient experiences, expectations, and satisfaction with diversity-sensitive care provided by healthcare providers.

METHODS

In December 2022 the Medline ALL, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO and additionally Google Scholar were searched for original studies that described or measured patient expectations, experiences, and/or satisfaction, specifically focusing on cultural or diversity competence of healthcare providers. Analysis of the collected data was performed using a convergent mixed-methods design based on thematic synthesis.

RESULTS

From initially 5,387 articles, 117 were selected for full-text screening, and ultimately, 34 articles were included in this study. The concept of diversity-sensitive care was observed to comprise three components. The first component is focused on patient-centered care and includes competencies such as clear and direct communication, shared decision-making, individualized care, empathy, and consideration. The second component centers on providing culturally tailored information, adjusting care to cultural needs, working with interpreters, allyship, community partnerships, self-awareness, and cultural knowledge, and builds upon the first component. Across the first two components of diversity-sensitive care, patients have reported experiencing dissatisfaction and encountering shortcomings in their healthcare providers, sometimes resulting in the third and final component pertaining to provider care. This component underscores the importance of linguistic, ethnic, cultural, and gender concordance in delivering quality care.

CONCLUSION

In conclusion, the patient perspective on diversity-sensitive care encompasses multiple components, from patient-centered care to concordant care. The components incorporate various competencies as communication skills, empathy, self-awareness and adjusting care to cultural needs. Patients reported experiencing dissatisfaction and shortcomings across all components of diversity-sensitive care provided by healthcare providers.

Evaluating the impact of 'Ask the Specialist Plus': a training program for improving cultural safety and communication in hospital-based healthcare

BACKGROUND

First Nations peoples in colonised countries often feel culturally unsafe in hospitals, leading to high self-discharge rates, psychological distress and premature death. To address racism in healthcare, institutions have promised to deliver cultural safety training but there is limited evidence on how to teach cultural safety. To that end, we created Ask the Specialist Plus: a training program that focuses on improving healthcare providers intercultural communication skills to improve cultural safety. Our aim is to describe training implementation and to evaluate the training according to participants.

METHODS

Inspired by cultural safety, Critical Race Theory and Freirean pedagogy, Ask the Specialist Plus was piloted at Royal Darwin Hospital in Australia's Northern Territory in 2021. The format combined listening to an episode of a podcast called Ask the Specialist with weekly, one-hour face-to-face discussions with First Nations Specialists outside the clinical environment over 7 to 8 weeks. Weekly surveys evaluated teaching domains using five-point Likert scales and via free text comments. Quantitative data were collated in Excel and comments were collated in NVivo12. Results were presented following Kirkpatrick's evaluation model.

RESULTS

Fifteen sessions of Ask the Specialist Plus training were delivered. 90% of participants found the training valuable. Attendees enjoyed the unique format including use of the podcast as a catalyst for discussions. Delivery over two months allowed for flexibility to accommodate clinical demands and shift work. Students through to senior staff learnt new skills, discussed institutionally racist systems and committed to behaviour change. Considering racism is commonly denied in healthcare, the receptiveness of staff to discussing racism was noteworthy. The pilot also contributed to evidence that cultural safety should be co-taught by educators who represent racial and gender differences.

CONCLUSION

The Ask the Specialist Plus training program provides an effective model for cultural safety training with high potential to achieve behaviour change among diverse healthcare providers. The training provided practical information on how to improve communication and fostered critical consciousness among healthcare providers. The program demonstrated that training delivered weekly over two months to clinical departments can lead to positive changes through cycles of learning, action, and reflection.

A qualitative study on opportunities to improve research engagement and inclusion of Black adults with systemic lupus erythematosus

In response to racial inequities in systemic lupus erythematosus (SLE), we aimed to identify practical recommendations for increasing engagement and inclusion of Black adults in SLE research. We used a qualitative, interpretive description approach and recruited 30 Black adults diagnosed with SLE in Michigan to participate in semi-structured interviews. Theme development focused on what factors influenced research perceptions and how research did not meet participant needs and expectations. We developed five main themes: (1) Ethical and equitable research. Participants shared how the impacts of past and present-day racism impacted their willingness to participate in research. (2) Trusting researchers to conduct studies and translate findings to health care. Participants had concerns related to researcher intentions and expressed the importance of communicating research outcomes to participants and translating findings to health care. (3) Drug trial beneficence. When considering drug trials, several people did not consider the potential benefits worth the risk of side effects, and some said they would need to consult with their doctor before agreeing to participate. (4) Altruism. Participants explained how the desire to help others was a motivating factor for participating in research and donating biological samples. (5) Research priorities. Participants described a need for better treatments that value their overall health and well-being. Findings indicate that researchers can center the perspectives of Black people with SLE across the research life cycle-beyond a focus on adequate racial diversity among study participants.

Planning the Implementation of a Multilevel Blood Pressure Control Intervention in Chicago: Community and Clinical Perspectives

Objectives

Hypertension is associated with high morbidity and mortality. The complications of hypertension disproportionately impact African American residents in Chicago's South Side neighborhood. To inform the implementation of an evidence-based multilevel hypertension management intervention, we sought to identify community member- and clinician-level barriers to diagnosing and treating hypertension, and strategies for addressing those barriers.

Methods

We conducted 5 focus groups with members of faith-based organizations (FBOs) (n=40) and 8 focus groups with clinicians and administrators (n=26) employed by community health centers (CHCs) located in Chicago's South Side.

Results

Participants across groups identified the physical environment, including lack of access to clinics and healthy food, as a risk factor for hypertension. Participants also identified inconsistent results from home blood pressure monitoring and medication side effects as barriers to seeking diagnosis and treatment. Potential strategies raised by participants to address these barriers included (1) addressing patients' unmet social needs, such as food security and transportation; (2) offering education that meaningfully engages patients in discussions about managing hypertension (eg, medication adherence, diet, follow-up care); (3) coordinating referrals via community-based organizations (including FBOs) to CHCs for hypertension management; and (4) establishing a setting where community members managing hypertension diagnosis can support one another.

Conclusions

Clinic-level barriers to the diagnosis and treatment of hypertension, such as competing priorities and resource constraints, are exacerbated by community-level stressors. Community members and clinicians agreed that it is important to select implementation strategies that leverage and enhance both community- and clinic-based resources.

Health equity integrated epilepsy care and research: A narrative review

BACKGROUND

With the unanimous approval of the Intersectoral Global Action Plan on epilepsy and other neurological disorders by the World Health Organization in May 2022, there are strong imperatives to work towards equitable neurological care.

AIMS

Using epilepsy as an entry point to other neurologic conditions, we discuss disparities faced by marginalized groups including racial/ethnic minorities, Americans living in rural communities, and Americans with low socioeconomic status.

MATERIALS AND METHODS

The National Institute on Minority Health Disparities Research Framework (NIMHD) was used to conduct a narrative review through a health equity lens to create an adapted framework for epilepsy and propose approaches to working towards equitable epilepsy and neurological care.

RESULTS

In this narrative review, we identified priority populations (racial and ethnic minority, rural-residing, and low socioeconomic status persons with epilepsy) and outcomes (likelihood to see a neurologist, be prescribed antiseizure medications, undergo epilepsy surgery, and be hospitalized) to explore disparities in epilepsy and guide our focused literature search using PubMed. In an adapted NIMHD framework, we examined individual, interpersonal, community, and societal level contributors to health disparities across five domains: (1) behavioral, (2) physical/built environment, (3) sociocultural, (4) environment, and (5) healthcare system. We take a health equity approach to propose initiatives that target modifiable factors that impact disparities and advocate for sustainable change for priority populations.

DISCUSSION

To improve equity, healthcare providers and relevant societal stakeholders can advocate for improved care coordination, referrals for epilepsy surgery, access to care, health informatics interventions, and education (i.e., to providers, patients, and communities). More broadly, stakeholders can advocate for reforms in medical education, and in the American health insurance landscape.

CONCLUSIONS

Equitable healthcare should be a priority in neurological care.

Advanced Nursing Practice and Advanced Practice Nursing roles within low and lower-middle-income countries

INTRODUCTION

Population health initiatives rely on the availability and skills of an appropriate workforce to meet required goals. One global workforce initiative with demonstrated ability to expand health care services and improve access to care is the development of Advanced Nursing Practice and Advanced Practice Nursing roles. Given the sparse published information about these roles in Low and Lower-Middle-Income countries, this study seeks to describe their development and application in these countries.

DESIGN

The researchers developed a descriptive cross-sectional multilingual survey for online distribution to nursing experts within the targeted countries. Survey questions addressed demographic information on the population served, Advanced Nursing Practice and Advanced Practice Nursing titles, the time frame and rationale for creating the title, and how the roles relate to the International Council of Nurses' Advanced Practice Nursing guidelines characteristics of education, practice, and regulation.

RESULTS

Of the 167 responses received, only 24 participants met the inclusion criteria. This represented five low-income countries and nineteen lower-middle-income countries from four World Bank regions. Seventy-one roles were identified. Roles emerged predominantly over the last 20 years, focusing on care for underserved populations, with an almost even spread across primary and acute care settings. There were differences in education, practice, and regulation amongst the roles. Roles that required a master's education or higher with practice-related characteristics had a broader scope of practice, which is consistent with international guidelines.

CONCLUSION

This paper describes how Advanced Nursing Practice and Advanced Practice Nursing roles from Low and Lower Middle-Income Countries have been implemented to address gaps in service and highlights disparities in education, practice and regulation compared to international guidelines. Maintaining and increasing support from organizations and universities internationally may be required to assist in developing and expanding educational programs for advanced nursing roles in these countries.

CLINICAL RELEVANCE

Understanding how these advanced nursing roles are operationalized in relation to education, practice, and regulation in Low and Lower-Middle-Income countries can provide baseline information that will inform workforce development policies to address healthcare needs in similar jurisdictions.

Evaluation of cultural competency in a South African cluster randomised controlled trial: lessons learned for trial reporting standards

BACKGROUND

Failure to consider relevant cultural, ethnic and diversity parameters (and the intersection between these parameters) during trial protocol development and trial conduct may negatively impact recruitment, intervention development and delivery, and participant adherence and retention, potentially reducing overall internal validity. This case study aimed to evaluate the utility and comparability between the 9-item Gibbs Framework to measure cultural competency and the GRIPP-2(Short Form (SF)) 5-point checklist to assess patient and public involvement in the context of a complex clinical trial conducted in an African setting.

METHODS

We identified and collated all relevant publications, source and procedural data related to the trial and integrated the documents into a dynamic trial timeline. Two independent investigators applied and scored the Gibbs Framework and the GRIPP-2(SF) checklist to the four publications arising from the trial, noting functionality and comparability between tools. Where cultural competency was not met, a third investigator screened all procedural and source data and identified if cultural competency had been achieved but not reported in the publications, or if the trial had not met appropriate cultural competency based on the documentation.

RESULTS

Application of the Gibbs Framework found that the trial scored '2' for seven of the nine Gibbs items, indicating full cultural competency for those questions. The Framework indicated that the trial research question was not driven by the articulated needs of patients, and neither were patients, caregivers and clinical providers involved in the development of the intervention. Comparability with the GRIPP-2(SF) checklist showed that the Gibbs performed better on evaluation of partnerships with the community, identification of culturally competent data sources and target populations, and appointment of trial staff in an inclusive manner.

CONCLUSIONS

Comprehensive evaluation of the trial's cultural competency required scrutiny of both published manuscripts and source and procedural data, suggesting that there is a gap in current trial reporting standards with respect to cultural competence.

TRIAL REGISTRATION

PACTR201610001825403. Registered on 17 October 2016.

Understanding and mitigating low health literacy

To take control of their health, patients and their families and carers need to understand the information they receive from healthcare professionals and be able to apply that information - in short, they require optimal health literacy. People with low health literacy may find it challenging to manage their condition and take steps to prevent ill-health, which may lead to an increased use of healthcare services. Low health literacy is one of the main barriers preventing healthcare professionals from adequately transmitting information to people in their care. It is crucial that nurses do not assume that everyone will understand information about their health, so nurses should adapt their communication and create an environment where people feel empowered to ask questions. This article describes factors affecting health literacy, explains the consequences of low health literacy, and identifies strategies and techniques nurses can use to mitigate low health literacy.

Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography

Background: This article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: “Why did he say that?” The article then proceeds to answer this question by showing how physicians’ most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare’s only widespread communication training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care’s “Verbatim” education modules. While the need for physicians’ emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care’s “Verbatim” education modules for physicians-in-training. Methods: This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care’s “Verbatim” education modules for identifying hidden emotions in clinical communication. Results: Using a profound personal example from the author’s firsthand experience of the suggested training tool, the “Verbatim” module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion: Spiritual Care’s “Verbatim” education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these communication modules for physicians-in-training may help to address physicians’ emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, introduced here: https://aquila.usm.edu/ojhe/vol17/iss1/7/.

Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography

Background : Intuitively accessible via WhyDidHeSayThat.com, this article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: "Why did he say that?" The article then proceeds to answer this question by showing how physicians' most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare's only widespread communication training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care's "Verbatim" education modules. While the need for physicians' emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care's "Verbatim" education modules for physicians-in-training. Methods : This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care's "Verbatim" education modules for identifying hidden emotions in clinical communication. Results : Using a profound personal example from the author's firsthand experience of the suggested training tool, the "Verbatim" module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion : Spiritual Care's "Verbatim" education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these communication modules for physicians-in-training may help to address physicians' emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, accessible via DoctorBodyCam.com.

Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography

Background: Intuitively accessible via WhyDidHeSayThat.com, this article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: “Why did he say that?” The article then proceeds to answer this question by showing how physicians’ most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare’s only widespread conversation analysis training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care’s “Verbatim” education modules. While the need for physicians’ emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care’s “Verbatim” education modules for physicians-in-training. Methods: This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care’s “Verbatim” education modules for conversation analysis and emotional intelligence.   Results: Using a profound personal example from the author’s firsthand experience of the suggested training tool, the “Verbatim” module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion: Spiritual Care’s “Verbatim” education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these conversation analysis modules for physicians-in-training may help to address physicians’ emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, accessible via DoctorBodyCam.com.

A Preliminary Study on the Cultural Competence of Nurse Practitioners and Its Affecting Factors

Cultural competence refers to a healthcare provider’s ability to consider cultural factors that affect an individual’s health and attitudes toward disease and disability. Nurse practitioners (NPs) are increasingly important in healthcare, practicing culturally competent care strategies to improve the quality of patient care. The aim of this study was to explore cultural competence and its related factors among NPs. A cross sectional study design with a structured questionnaire survey was used. Purposive sampling was employed, for which 86 NPs were recruited from a medical center in northern Taiwan. A T-test, one-way ANOVA, and Pearson’s product-moment correlation coefficient were used for data analysis. The results were as follows: (1) overall, the total score for cultural competence was above-average, with a score of 3.75; (2) years of experience as a NP was found to have a statistically significant correlation with overall clinical competence, with r = 0.23, p < 0.05; (3) there were significant differences in clinical awareness and cultural sensitivity related to the clinical ladder system (t = −2.42, p = 0.01; t = −2.04, p = 0.04). The findings of this study can provide information for directors of medical institutions to design an in-service educational program for NPs to enhance their cultural competence and nursing quality.

Nursing students' experience of learning cultural competence

INTRODUCTION

European societies are rapidly becoming multicultural. Cultural diversity presents new challenges and opportunities to communities that receive immigrants and migrants, and highlights the need for culturally safe healthcare. Universities share a responsibility to build a fair and equitable society by integrating cultural content in the nursing curricula. This paper aims to analyze European student nurses´ experience of learning cultural competence and of working with patients from diverse cultural backgrounds.

MATERIALS AND METHODS

A phenomenological approach was selected through a qualitative research method. 7 semi-structured focus groups with 5-7 students took place at the participants' respective universities in Spain, Belgium, Turkey and Portugal.

RESULTS

5 themes and 16 subthemes emerged from thematic analysis. Theme 1, concept of culture/cultural diversity, describes the participants' concept of culture; ethnocentricity emerged as a frequent element in the students' discourse. Theme 2, personal awareness, integrates the students' self-perception of cultural competence and their learning needs. Theme 3, impact of culture, delves on the participants' perceived impact of cultural on both nursing care and patient outcomes. Theme 4, learning cultural competence, integrates the participants' learning experiences as part of their nursing curricula, as part of other academic learning opportunities and as part of extra-academic activities. Theme 5, learning cultural competence during practice placements, addresses some important issues including witnessing unequal care, racism, prejudice and conflict, communication and language barriers, tools and resources and positive attitudes and behaviors witnesses or displayed during clinical practice.

CONCLUSION

The participants' perceived level of cultural competence was variable. All the participants agreed that transcultural nursing content should be integrated in the nursing curricula, and suggested different strategies to improve their knowledge, skills and attitudes. It is important to listen to the students and take their opinion into account when designing cultural teaching and learning activities.